Cases & Commentaries

In anticipation of discharge, a patient's opiate medication is changed from an immediate-release to a long-acting formbut the dose was incorrectly converted, resulting in an overdose. The patient develops respiratory distress and requires a 2-week stay in the ICU.

Cases & Commentaries

For a woman with insulin-dependent diabetes mellitus, the admitting medical team ordered sliding scale insulin. Her blood glucose levels became very difficult to control, and she developed diabetic ketoacidosis. In the morning, the physician instituted a more appropriate insulin regimen.

Cases & Commentaries

A pregnant woman with asthma was admitted to the hospital with respiratory distress. Although the emergency department providers noted that she was pregnant, this information was not conveyed to the floor. On admission, the patient was given an antibiotic that could have been dangerous.

Cases & Commentaries

A powerful anti-clotting medication is ordered for a patient admitted for coronary intervention. Due to a forcing function in the computer order entry system, the intern enters an arbitrary maintenance infusion rate, assuming that the pharmacy will fix it if it is wrong. The pharmacy dispenses it as written, and the nurse administers it—underdosing the patient by a factor of 40.

Cases & Commentaries

A 91-year-old woman is found lethargic and incontinent, with slurred speech. Review of her medications reveals numerous duplicates, including some considered potentially inappropriate for use in elderly patients.

Cases & Commentaries

An elderly woman presented to the emergency department following a hip fracture. Although the patient's medication bottles were used to generate a medication list, one of the dosages was transcribed incorrectly. Because the patient then received four times her regular dose, her surgery was delayed due to cardiac side effects.

Cases & Commentaries

Antibiotics administration for an elderly man hospitalized for acute infection is delayed by more than 24 hours due to a mix-up and override in the computerized provider order entry system. However, none of the clinicians on the floor questioned the delay.

Cases & Commentaries

While entering an order via smartphone to discontinue anticoagulation on a patient, a resident received a text message from a friend and never completed the order. The patient continued to receive warfarin and had spontaneous bleeding into the pericardium that required emergency open heart surgery.

Cases & Commentaries

A cancer patient expecting to be discharged from the hospital after his usual 3-day regimen was surprised to hear that he has 2 more days of chemotherapy. He asked to speak with the oncology team, who discovered that although the right medications were ordered, the wrong duration and dosage were selected on the order set.

Cases & Commentaries

A triage nurse incorrectly recorded a toddler's weight as 25 kg, instead of 25 lbs, which led to an error in calculating the dosage for antibiotics. She entered the inaccurate weight into the electronic medical record, and none of the other providers who saw the child caught the error.

Cases & Commentaries

An epilepsy patient's discharge plan included phenytoin to be taken once daily. The prescribing physician was somewhat unfamiliar with the electronic medical record (EMR), didn't notice that the default frequency for phenytoin was "TID," and overrode the resultant computerized alert about the high dosage.

Cases & Commentaries

Following urgent catheter-directed thrombolysis to relieve acute limb ischemia caused by thrombosis of her left superficial femoral artery, an elderly woman was admitted to the ICU. While ordering a heparin drip, the resident was unaware that the EHR order set had undergone significant changes and inadvertently ordered too low a heparin dose. Although the pharmacist and bedside nurse noticed the low dose, they assumed the resident selected the dose purposefully. Because the patient was inadequately anticoagulated, she developed extensive thrombosis associated with the catheter and sheath site, requiring surgical intervention for critical limb ischemia (including amputation of the contralateral leg above the knee).

Journal Article > Study

This study analyzed nearly 290,000 medication orders during a 1-year study period to determine the rates and risk factors for prescribing errors. Results indicated an overall error rate of 3.13 errors per 1000 orders written, with the greatest rate seen between noon and 4 pm and among first-year residents. Additional data presented include classes of medication involved in errors, types of errors detected, and frequency of errors by specialty service. The authors conclude that medication errors pose a significant safety risk in teaching hospitals and that system interventions, such as appropriate monitoring of prescribing habits and educational training programs, must be emphasized.

Using a designated criteria system for inappropriate medication prescribing, this study examined the impact of such prescriptions on hospitalization and death. Studying more than 3300 nursing home residents, investigators reported greater odds of being hospitalized in the month following an inappropriate prescription, an associated greater risk of death, and similar risk with even intermittent exposure to such prescriptions. The authors conclude that their reported associations call for improved attention and education for providers who prescribe medications to the elderly.

This study evaluated the capacity of electronic alerts to reduce inappropriate prescribing of medications to inpatients with renal insufficiency. Investigators studied the likelihood of inappropriate prescribing 4 months before and 14 months after implementation of the automated alert system. Results indicated a nearly 50% decrease in administration of contraindicated medications and that receptivity to the alert system was greater in more experienced housestaff. The authors conclude that similar decision support systems can reliably improve care, but success of these systems requires provider compliance.

Journal Article > Commentary

The Joint Commission on Accreditation of Healthcare Organization's (JCAHO) National Patient Safety Goals advocate for hospitals to ensure medication reconciliation as part of their safety strategy. This article shares the views of a single institution in its efforts to construct reconciliation forms, design processes for use, and then audit the forms after put into practice. The authors offer a series of lessons learned from their implementation experience and suggest that future success relies on a team-oriented approach with consistent communication.

This study reports the findings of a survey administered to medical trainees about the safety of their prescribing behaviors. Results suggested an inconsistent use of safe prescribing practices, such as checking for drug allergies, assuring normal renal function, and addressing potential drug interactions. The authors conclude by advocating for greater efforts toward safer prescribing strategies with emphasis on trainee education.

Journal Article > Study

This study examined the incidence of prescribing errors that occurred on-call, post-call, and off-call for a group of residents at a single teaching hospital. Through a retrospective chart review, investigators discovered that orders written either on-call or post-call were associated with a greater error rate than those written on an off-call day. Results also suggested increased error rates with medication orders when written by less experienced residents and for patients on general medical/surgical services. The authors conclude that additional research to understand the contributing factors will provide a strategy for necessary intervention.